Provider Demographics
NPI:1124384045
Name:MABIALA, PRINCE
Entity Type:Individual
Prefix:MR
First Name:PRINCE
Middle Name:
Last Name:MABIALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 N COUNTRY CLUB RD APT A4
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-2501
Mailing Address - Country:US
Mailing Address - Phone:520-808-3775
Mailing Address - Fax:520-748-2355
Practice Address - Street 1:2575 N COUNTRY CLUB RD APT A4
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2501
Practice Address - Country:US
Practice Address - Phone:520-808-3775
Practice Address - Fax:520-748-2355
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ343900000X
AZATN9038347C00000X
AZAPF8708347C00000X
AZAVF9340347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)